Forms

Forms for Consumers
Forms for Applicants
- General Applications
- Advanced Practice Applications
Forms for Licensees
Enforcement Forms
Probation Forms
Intervention Forms
Forms for Nursing Programs

Consumers

Document Title
Customer Service Evaluation Form
Speaker Request Form

Applicants

General Applications

Document Title
Licensure by Examination Instructions and Supplemental Forms
Licensure by Examination (8-Year Retake) Fee Schedule and Instructions
Licensure by Endorsement Instructions and Supplemental Forms
Breakdown of International Nursing Educational Program
International Diploma Verification Form
International License Verification Form
Notification of Social Security Number Change
Request for Accommodation of Disabilities
Request for Transcript

Advanced Practice Applications

Document Title
Public Health Nurse Certificate Application Instructions and Supplemental Forms
Clinical Nurse Specialist (CNS) Certification Application Instructions and Supplemental Forms
Nurse Anesthetist (NA) Certification Application Instructions and Supplemental Forms
Nurse-Midwife (NM) Certification Application Instructions and Supplemental Forms
Nurse Practitioner (NP) Certification Application Instructions and Supplemental Forms
Psychiatric/Mental Health (P/MH) Nurse Application Instructions and Supplemental Forms
Nurse Midwife Furnishing Number Application Instructions and Supplemental Forms
Nurse Practitioner Furnishing Number Application Instructions and Supplemental Forms

Education

Document Title
Continuing Approval - Nursing Program
Instructions for Institutions Seeking Approval of New Prelicensure Registered Nursing Program
New School of Nursing - Feasibility Study Report
Request for Major Curriculum Revision

Licensees

Document Title
Active to Inactive License
Application for Reinstatement of a Lapsed License - 8-Year Renewal
Continuing Education Provider Initial Renewal Notice
Notification of Social Security Number Change
Renewal Fingerprint Question Certification
Request for Duplicate Certificate

Enforcement

Document Title
Complaint
Expert Practice Consultant Application
Health Facility Reporting Form (805 Report)
Report of Settlement, Judgment, or Arbitration Award

Probation

Initial Probation Forms
Fingerprint Instructions and Form – BRNPROB114
Vault Enrollment Instructions – BRNPROB115
Data Report Form – BRNPROB118
EDD Authorization for Release – BRNPROB119
Confidential Release Form – BRNPROB107
Cost Recovery – Payment Plan – BRNPROB117

Employment Forms
Employment Approval Form – BRNPROB113
Employer Agreement and Attestation – BRNPROB426
Worksite Monitor Agreement and Attestation- BRNPROB427
Home Health – Employer Agreement and Attestation – BRNPROB428
Home Health – Worksite Monitor Agreement and Attestation – BRNPROB429

Work Performance Evaluations
RN Work Performance Evaluation – BRNPROB101
NP Work Performance Evaluation – BRNPROB102
CRNA Work Performance Evaluation – BRNPROB103

12-Step/Nurse Support Group
AA-NSG Calendar – BRNPROB100
NSG Facilitator Form – BRNPROB110
NSGF Confidential Release Form – BRNPROB124

Mental/Physical Health Exams and Drug Testing-Related Forms
Physical Examination Form – BRNPROB108
Mental Examination Form – BRNPROB112
Rehabilitation & Treatment Form – BRNPROB116
Relapse Prevention Plan – BRNPROB122
Rule Out Exam Addendum – BRNPROB123
Psychotropic Mood Altering Drug Form – BRNPROB111
Therapy Form – BRNPROB109

Tolled Update Forms
Tolled Update Form – BRNPROB105
Tolled – Request to go into Tolled Status – BRNPROB106

Refresher Course Information
Refresher Course and Clinical Approval Form – BRNPROB120

Petition Forms – Modification and Early Termination
Process for Filing a Petition – BRNDECAPP-01
Petition for Early Termination of Probation – BRNDECAPP-05
Petition for Modification of Probation – BRNDECAPP-06

Intervention

Document Title
Application for Nurse Support Group Facilitator/Co-Facilitator
Intervention Evaluation Committee (IEC) Application